Spring Ridge Retirement, LLC

Facility unable to provide inspection documentation for all fire-resistant-rated construction assemblies. Staff lacked awareness of what constitutes fire-resistant-rated construction.

Missing quarterly sprinkler inspection documentation, annual forward flow test report, and 5-year FDC hydro test report.

Conference table and chairs found impeding access to memory care exit vestibule leading to parking lot.

Unable to provide documentation showing that annual servicing of the emergency backup generator has been performed in the past 12 months.

Class K fire extinguisher in kitchen is missing monthly inspection sign offs.

Double doors to the library room have an excessive center gap between the door leaves.

Unable to provide records showing twelve planned and unannounced fire drills in the past 12 months; facility must conduct fire drills for all three shifts in December 2024.

Unable to provide last annual inspection of all fire-resistant-rated construction assemblies, and/or records of repairs.

Unable to provide record showing that fire doors have been annually inspected, tested and repaired in the past 12 months.

Corridor door by room 23 failed to self-close when tested.

Unsealed penetrations observed in the communications room, around conduit.

Unable to provide quarterly inspection reports, last annual forward flow test report, and last 5-year FDC hydro test report.

Unable to provide documentation showing resident room smoke alarms have been tested and maintained.

Unable to provide documentation showing annual servicing of the fire alarm system in the past 12 months.

Unable to provide documentation showing monthly inspection of carbon monoxide alarms.

Unable to provide documentation showing 30-second monthly battery testing of emergency lighting and exit signs.

Unable to provide documentation showing 90-minute annual battery testing of emergency lighting and exit signs.

Conference table and chairs found impeding access to memory care exit vestibule.

Unable to provide documentation showing annual servicing of the emergency backup generator.

Facility failed to provide records of twelve planned and unannounced fire drills conducted in the past 12 months for each shift.

The facility failed to protect the rights of 2 residents by isolating them in their rooms for 6-7 days due to bed bugs, leading to a loss of dignity and a sense of isolation.

Edited; removed a specific progress note from 01/03/2024.

Edited; added a specific date and time to a progress note review.

Edited; removed the phrase "in the following days".

The licensee failed to investigate, determine causes, and institute interventions to prevent recurrence for a resident's health incident, leading to ongoing medication error risks.

Facility failed to investigate the source of a respiratory outbreak, manage the spread of infection, or ensure proper infection control practices.

Facility failed to investigate, determine causes, and implement interventions for resident medication incidents and safety affecting resident health.

Facility failed to ensure safe medication practices, resulting in over-medication, incorrect dosages, and unauthorized medication changes for multiple residents.

The facility failed to conduct proper investigations into pressure ulcers for Resident 1 and injuries of unknown source (bruising) for Residents 2 and 3. Staff and the Administrator were unable to provide evidence of thorough investigations or clear conclusions for these incidents.

The facility failed to provide showers as agreed upon in the Negotiated Service Plan for 3 sampled residents, placing them at risk for poor hygiene and skin issues. There was no documentation showing if showers were given, attempted, or refused.